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| {{Infobox_Disease |
| | #REDIRECT[[Epididymoorchitis]] |
| Name = Epididymitis |
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| Image = Illu testis surface.jpg |
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| Caption = 1: Epididymis<BR>2: Head of epididymis<BR>3: Lobules of epididymis<BR>4: Body of epididymis<BR>5: Tail of epididymis<BR>6: Duct of epididymis<BR>7: Deferent duct (ductus deferens or [[vas deferens]]) |
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| DiseasesDB = 4342 |
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| ICD10 = {{ICD10|N|45|0|n|40}} |
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| ICD9 = {{ICD9|604}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = med |
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| eMedicineTopic = 704 |
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| eMedicine_mult = {{eMedicine2|radio|261}} {{eMedicine2|emerg|166}} |
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| MeshID = D004823 |
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| }}
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| [[Image:SOA-epididymites.jpg|right|thumb|Epididymitis (left side) due to [[Gonorrhea]] infection.]]
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| {{Search infobox}}
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| {{SCC}}
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| {{Editor Join}}
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| ==Overview==
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| '''Epididymitis''' is a [[medicine|medical]] condition in which there is [[inflammation]] of the [[epididymis]] (a curved structure at the back of the [[testicle]] in which [[sperm]] matures and is stored). This condition may be mildly to very [[pain]]ful, and the [[scrotum]] (sac containing the testicles) may become red, warm and swollen. It may be acute (of sudden onset) or rarely chronic.
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| [[Epididymitis]] is the most frequent cause of [[scrotal pain]]. In contrast with men who have [[testicular torsion]], the [[cremaster reflex]] (elevation of the testicle in respons to stroking the upper inner thigh) is not altered. If the diagnosis is not entirely clear from the patient's [[Medical history|history]] and [[physical examination]], a [[Doppler ultrasound|Doppler ultrasound scan]] can confirm increased flow of blood to the affected epididymis.
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| [[Infection]] is the most common cause. In sexually active men, ''[[Chlamydia trachomatis]]'' is the most frequent causative microbe, followed by [[Escherichia coli|''E. coli'']] and ''[[Neisseria gonorrhoeae]]''. In children, it may follow an infection in another part of the body (for example, a viral illness), or there may be an associated [[urinary tract]] anomaly. Another cause is sterile reflux of urine through the [[ejaculatory duct]]s. [[Antibiotic]]s may be needed to control a component of [[infection]]. Treatment otherwise comprises [[pain killers]] or [[non-steroidal anti-inflammatory drug|anti-inflammatory drugs]] and [[bed rest]] if necessary, and symptom control by resting the scrotum in a supported position.
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| ==Causes==
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| Infection is the most common cause of epididymitis. The [[bacterium|bacteria]] in the [[urethra]] back-track through the [[urinary tract|urinary]] and [[human reproductive system|reproductive structures]] to the epididymis. There can be associated [[urethritis]] (inflammation of the urethra). Rarely, the infection reaches the epididymis via the bloodstream.
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| In sexually active men, ''[[Chlamydia trachomatis]]'' is responsible for two-thirds of cases, followed by ''[[Neisseria gonorrhoeae]]'' and [[E. coli]] (or other bacteria that cause [[urinary tract infection]]). Less common microbes include ''[[Ureaplasma]]'', [[Mycobacterium]], and [[cytomegalovirus]], or [[Cryptococcus]] in patients with [[HIV infection]]. ''E. coli'' is more common in boys before [[puberty]], the [[elderly]] and [[homosexual men]].
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| Non-infectious causes are also possible. Reflux of sterile urine (urine without bacteria) through the [[ejaculatory duct]]s may cause inflammation with obstruction. In children, it may be a response following an infection with [[enterovirus]], [[adenovirus]] or ''[[Mycoplasma pneumoniae]]''.
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| Epididymitis can also be caused by genito-urinary [[surgery]], including [[prostatectomy]] and [[urinary catheterization]]. [[Congestive epididymitis]] is a long-term complication of [[vasectomy]].<ref name="pmid10785217">{{cite journal |author=Schwingl PJ, Guess HA |title=Safety and effectiveness of vasectomy |journal=Fertil. Steril. |volume=73 |issue=5 |pages=923–36 |year=2000 |pmid=10785217 |doi= |doi=10.1016/S0015-0282(00)00482-9}}</ref><ref name="pmid8237740">{{cite journal |author=Raspa RF |title=Complications of vasectomy |journal=American family physician |volume=48 |issue=7 |pages=1264–8 |year=1993 |pmid=8237740 |doi=}}</ref> Chemical epididymitis may also result from drugs such as [[amiodarone]].<ref name="amiodarone">{{cite journal |author=Ibsen HH, Frandsen F, Brandrup F, Møller M |title=Epididymitis caused by treatment with amiodarone |journal=Genitourin Med |volume=65 |issue=4 |pages=257–8 |year=1989 |month=August |pmid=2807285 |doi= |url=}} {{PMC|1194364}}</ref>
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| ==Diagnosis==
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| Epididymitis can be hard to distinguish from [[testicular torsion]]. Both can occur at the same time. A [[urologist]] may need to be consulted.
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| Epididymitis usually has a gradual onset. On [[physical examination]], the testicle is usually found to be in its normal vertical position, of equal size compared to its counterpart, and not high-riding. Typical findings are redness, warmth and swelling of the scrotum, with tenderness behind the testicle, away from the middle (this is the normal position of the epididymis relative to the testicle). The [[cremasteric reflex]] (if it was normal before) remains normal. This is a useful sign to distinguish it from [[testicular torsion]]. If there is pain relieved by elevation of the testicle, this is called [[Prehn's sign]], which is however non-specific.
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| [[Urinalysis|Analysis of the urine]] may or may not be normal. Before the advent of sophisticated [[medical imaging]] techniques, surgical exploration was the standard of care. Nowadays, color [[Doppler ultrasound]] is the preferred test. It can demonstrated increased blood flow (also compared to the normal side), as opposed to [[testicular torsion]]. [[Nuclear medicine|Nuclear]] testicular blood flow testing is rarely used.
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| Additional tests may be necessary to identify underlying causes. In younger children, a urinary tract anomaly is frequently found. In sexually active men, tests for [[sexually transmitted disease]]s may be done. These may include [[microscopy]] and [[Microbiological culture|culture]] of a first void urine sample, [[Gram stain]] and culture of fluid or a swab from the [[urethra]], nuclear acid amplification tests (to amplify and detect microbial [[DNA]] or other [[nucleic acid]]s) or tests for [[syphillis]] and [[HIV]].
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| ===Ultrasound===
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| *The epididymal head is the most affected region, and reactive [[hydrocele]] and wall thickening are frequently present.
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| *Increased size and, depending on the time of evolution, decreased, increased, or heterogeneous echogenicity of the affected organ are usually observed.
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| *The inflammation produces increased blood flow within the epididymis, testis, or both.
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| *Analysis of the epididymal waveform may reveal a low-resistance pattern as compared with the normal pattern.
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| ([http://www.radswiki.net Images courtesy of RadsWiki])
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Epididymitis 001.jpg|USG image demonstrates epididymitis
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| Image:Epididymitis 002.jpg|USG image demonstrates epididymitis
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Severe epididymitis001.jpg|Severe epididymitis with focal abscess formation
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| Image:Severe epididymitis002.jpg|Severe epididymitis with focal abscess formation
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Severe epididymitis003.jpg|Severe epididymitis with focal abscess formation
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| Image:Severe epididymitis004.jpg|Severe epididymitis with focal abscess formation
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| </gallery>
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| </div>
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| ===MRI===
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| ([http://www.radswiki.net Images courtesy of RadsWiki])
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Severe epididymitis005.jpg|Severe epididymitis with focal abscess formation
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| Image:Severe epididymitis006.jpg|Severe epididymitis with focal abscess formation
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| Image:Severe epididymitis007.jpg|Severe epididymitis with focal abscess formation
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| </gallery>
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| </div>
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| ==Complications==
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| Most cases with adequate treatment develop no complications and don't result in infertility. Untreated, acute epididymitis can lead to a variety of complications. These include chronic epididymitis, [[abscess]], permanent damage or even destruction of the [[epididymis]] and [[testicle]] (resulting in [[infertility]] and/or [[hypogonadism]]), and [[infection]] may spread to any other [[organ (anatomy)|organ]] or system of the body.
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| ==Treatment==
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| [[Antibiotics]] are used if an infection is suspected. [[Fluoroquinolone]]s are an option, although resistance of ''[[N. gonorrhoeae]]'' may limit their use. A [[cephalosporin]] (such as [[ceftriaxone]]) combined with [[doxycycline]] is an alternative. [[Azithromycin]] can be used for susceptible strains. In children, quinolones and doxycycline are best avoided. Since bacteria that cause urinary tract infections are often the cause of epididymitis in children, [[co-trimoxazole]] or suited [[penicillin]]s (for example, [[cephalexin]]) can be used. If there is a sexually transmitted disease, the partner should also be treated.
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| Household remedies such as elevation of the [[scrotum]] and cold compresses applied regularly to the [[scrotum]] may relieve the pain. [[Painkillers]] or [[non-steroidal anti-inflammatory drugs|anti-inflammatory drugs]] are often necessary. Hospitalisation is indicated for severe cases, and check-ups can ensure the [[infection]] has cleared up. [[Surgery]] is rarely necessary, for example in those rare instances where an [[abscess]] forms.
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| ==Chronic epididymitis==
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| Chronic epididymitis is epididymitis which ensues for more than six weeks. Chronic epididymitis is characterised by [[inflammation]] even when there is no [[infection]] present. Tests are needed to distinguish chronic epididymitis from a range of other disorders that can cause constant scrotal pain. These include [[testicular cancer]], enlarged scrotal veins ([[varicocele]]) or a [[cyst]] within the [[epididymis]]. As well, the nerves in the scrotal area are connected to those of the abdomen, sometimes causing pain similar to a [[hernia]] (see [[referred pain]]). This condition can develop even without the presence of the previously described known causes.
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| Typically, a second, longer round of treatment is used. It is believed that the [[hypersensitivity]] of certain structures, including nerves and muscles, may cause or contribute to chronic epididymitis. A procedure called a cord block is a last measure. This consists of an injection into the nerve that traces along the epididymis. The injection is a compound of several medications including a [[glucocorticoid|steroid]], pain killers, and a high dose of an anti-inflammatory. This treatment can quell the pain for 2-3 months in ideal conditions. Some patients may only experience an even shorter duration of 2-3 days, while the fortunate ones in rare occasions are never bothered again. This procedure would of course have to be repeated when necessary, until the problem goes away completely, or until the routine is simply too bothersome. As a last resort, a patient may then decide to have the epididymis completely removed.
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| ==Pathological Findings==
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Epididymitis 0001.jpg|Testes: Epididymitis, Chronic; Inflammation Centered on Epididymal Tubules
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| Image:Epididymitis 0002.jpg|Testes: Epididymitis with Sperm Granulomas; Note Dystrophic Calcification
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Epididymitis 0003.jpg|
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| Image:Epididymitis 0004.jpg|
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Epididymitis 0005.jpg|
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| Image:Epididymitis 0006.jpg|
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| </gallery>
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| </div>
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| ==References==
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| <references/>
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| ==See Also==
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| *[[Testicular torsion]]
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| ==Further reading==
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| *{{cite journal |author=Galejs LE |title=Diagnosis and treatment of the acute scrotum |journal=Am Fam Physician |volume=59 |issue=4 |pages=817–24 |year=1999 |month=February |pmid=10068706 |doi= |url=http://www.aafp.org/afp/990215ap/817.html}}
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| *{{cite journal |author=Nickel JC |title=Chronic epididymitis: a practical approach to understanding and managing a difficult urologic enigma |journal=Rev Urol |volume=5 |issue=4 |pages=209–15 |year=2003 |pmid=16985840 |doi= |url=}} {{PMC|1553215}}
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| * Celestino Aso, Goya Enríquez, Marta Fité, Nuria Torán, Carmen Piró, Joaquim Piqueras, and Javier Lucaya. [http://radiographics.rsnajnls.org/cgi/content/abstract/25/5/1197 Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An Update.] RadioGraphics 2005 25: 1197-1214.
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| * Paula J. Woodward, Cornelia M. Schwab, and Isabell A. Sesterhenn. [http://radiographics.rsnajnls.org/cgi/content/abstract/23/1/215 From the Archives of the AFIP: Extratesticular Scrotal Masses: Radiologic-Pathologic Correlation.] RadioGraphics 2003 23: 215-240.
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| ==External links==
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| * {{DMOZ|Health/Men%27s_Health/Conditions_and_Diseases/Epididymitis/}}
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| *[http://goldminer.arrs.org/search.php?query=Epididymo-orchitis Goldminer: Epididymo-orchitis]
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| {{Diseases of the pelvis, genitals and breasts}}
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| {{SIB}}
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| [[Category:Andrology]]
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| [[Category:Urology]]
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| [[Category:Inflammations]]
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| [[Category:Emergency medicine]]
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| [[de:Epididymitis]]
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| [[it:Epididimite]]
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| [[nl:Epididymo-orchitis]]
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| [[pt:Epididimite]]
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| [[simple:Epididymitis]]
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| [[sv:bitestikelinflammation]]
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| {{WH}}
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| {{WS}}
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